Inpatient HTN: What to do?

Your pager’s blowing up…

“THE PATIENT’S BLOOD PRESSURE IS 160/90”

“IT IS NOW 164/82″ 

“IT IS NOW 158/90”

“PT IS ASYMPTOMATIC. BUT IT IS NOW BACK UP TO 160/90″


Background:

  • Inpatient HTN has a prevalence of ~50-72%. 
  • Despite evidence for BP management in primary care, evidence to support treatment inpatient is lacking. 

Aims:

  • To quantify the prevalence of inpatient HTN
  • To characterize hospitalists’ response to elevated BP
  • To compare short- and long-term outcomes between patients who were and were not treated at comparable severities of HTN

Methods: 

  • Retrospective propensity matched cohort study
  • ~22k adult patients at 10 Cleveland Clinic hospitals admitted to the internal medicine service with at least one SBP >140
  • Data collected: 
    • Demographic details (age, sex, andrace/ethnicity)
    • Comorbidities (cardiovascular disease, diabetes, CKD)
    • BP characteristics (maximal SBP and DBP, time from admission, hospital shift during which BP was measured, change from prior SBP, proportion of the previous 2 measures that were elevated)
    • Medication information (outpatient regimen, inpatient IV and oral antihypertensives)
  • Outcome measures:
    • Acute treatment of elevated BP
    • AKI, myocardial injury, stroke, and a composite of all 3
    • Medication intensification at discharge; BP control in year after discharge

Results: 

  • 78% of adult patients admitted for noncardiovascular diagnoses had at least 1 hypertensive BP measurement. 
  • Fewer than 1 in 3 had their medication intensified. 

  • Table 3: “Compared with propensity-matched patients who did not receive treatment, those who did were more likely to experience the composite outcome, AKI, and myocardial injury. Inpatient stroke was extremely rare. Length of stay after the index BP did not differ between treated and untreated patients.”

  • Table 4: “In the 30 days post-discharge, patients with and without intensification had similar rates of myocardial infarction or stroke. In the following year, patients with and without intensification had nearly identical BP control, including proportion of hypertensive systolic and diastolic pressures and maximum SBP and DBP. Both groups had slight reduction of average SBP compared with their discharge SBP.” 

Conclusions: 

  • “Finally, even if treatment of elevated BP in the hospital does not result in harm, we found no indication that it was beneficial. It was, at best, a waste of time and resources.”

Mic dropped. 


Blog post based on Med-Peds Forum talk by Rebecca Moore, PGY4